Primary care

Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need.[1][2][3] Patients commonly receive primary care from professionals such as a primary care physician (general practitioner or family physician), a nurse practitioner (adult-gerontology nurse practitioner, family nurse practitioner, or pediatric nurse practitioner), or a physician assistant. In some localities, such a professional may be a registered nurse, a pharmacist, a clinical officer (as in parts of Africa), or an Ayurvedic or other traditional medicine professional (as in parts of Asia). Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.

Primary care may be provided in community health centres.

Background

The World Health Organization attributes the provision of essential primary care as an integral component of an inclusive primary healthcare strategy. Primary care involves the widest scope of healthcare, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Consequently, a primary care practitioner must possess a wide breadth of knowledge in many areas. Continuity is a key characteristic of primary care, as patients usually prefer to consult the same practitioner for routine check-ups and preventive care, health education, and every time they require an initial consultation about a new health problem. Collaboration among providers is a desirable characteristic of primary care.

The International Classification of Primary Care (ICPC) is a standardized tool for understanding and analyzing information on interventions in primary care by the reason for the patient visit.[4] Common chronic illnesses usually treated in primary care may include, for example: hypertension, angina, diabetes, asthma, COPD, depression and anxiety, back pain, arthritis or thyroid dysfunction. Primary care also includes many basic maternal and child health care services, such as family planning services and vaccinations.

In context of global population ageing, with increasing numbers of older adults at greater risk of chronic non-communicable diseases, rapidly increasing demand for primary care services is expected around the world, in both developed and developing countries.[5][6]

Funding for primary care varies a great deal between different countries: general taxation, national insurance systems, private insurance and direct payment by patients are all used, sometimes in combination. The payment system for primary care physicians also varies. Some are paid by fee-for-service and some by capitation for a list of registered patients.[7]

Primary care by country

United Kingdom

In the United Kingdom, patients can access primary care services through their local general practice, community pharmacy, optometrist, dental surgery and community hearing care providers. Services are generally provided free-of-charge through the National Health Service. In the UK, unlike many other countries, patients do not normally have direct access to hospital consultants and the GP controls access to secondary care.[8] This practice is referred to as "gatekeeping"; the future of this role has been questioned by researchers who conclude "Gatekeeping policies should be revisited to accommodate the government’s aim to modernise the NHS in terms of giving patients more choice and facilitate more collaborative work between GPs and specialists. At the same time, any relaxation of gatekeeping should be carefully evaluated to ensure the clinical and non-clinical benefits outweigh the costs".[9]

Canada
Main article: Health care in Canada

In Canada, access to primary and other healthcare services is guaranteed for all citizens through the Canada Health Act.

Nigeria

In Nigeria, healthcare is a concurrent responsibility of three tiers of government. Local governments focus on the delivery of primary care (e.g. through a system of dispensaries), state governments manage the various general hospitals (secondary care), while the federal government's role is mostly limited to coordinating the affairs of the Federal Medical Centres and university teaching hospitals (tertiary care).

United States

As of 2012, there were about six primary care professional societies in the United States, including American College of Physicians, American Academy of Family Physicians, the Society of General Internal Medicine, the American Academy of Pediatrics, the American Osteopathic Association, and the American Geriatrics Society.[10]

A 2009 report by the New England Healthcare Institute determined that an increased demand on primary care by older, sicker patients and decreased supply of primary care practitioners has led to a crisis in primary care delivery. The research identified a set of innovations that could enhance the quality, efficiency and effectiveness of primary care in the United States.[6]

On March 23, 2010 President Obama signed the Patient Protection and Affordable Care Act (ACA) into law. The law is estimated to have expanded health insurance coverage by 20 million people by early 2016[11] and is expected to expand health care to 34 million people by 2021.[12] The success of the expansion of health insurance under the ACA in large measure depends on the availability of primary care physicians. Unfortunately, The ACA has drastically exacerbated the projected deficit of primary care physicians needed to ensure care for insured Americans. According to the Association of American Medical Colleges (AAMC) without the ACA, the United States would have been short roughly 64,000 physicians by 2020; with the implementation of the ACA, it will be 91,000 physicians short. According to the AAMC's November 2009 physician work force report, nationally, the rate of physicians providing primary care is 79.4 physicians per 100,000 residents.[12]

Primary healthcare results in better health outcomes, reduced health disparities and lower spending, including on avoidable emergency department visits and hospital care. With that being said, primary care physicians are an important component in ensuring that the healthcare system as a whole is sustainable. However, despite their importance to the healthcare system, the primary care position has suffered in terms of its prestige in part due to the differences in salary when compared to doctors that decide to specialize. In a 2010 national study of physician wages conducted by the UC Davis Health System found that specialists are paid as much as 52 percent more than primary care physicians, even though primary care physicians see far more patients.[13]

Primary care physicians earn $60.48 per hour; specialists on average earn $88.34.[13] A follow up study conducted by the UC Davis Health System found that earnings over the course of the careers of primary care physicians averaged as much as $2.8 million less than the earnings of their specialist colleagues.[14] This discrepancy in pay has potentially made primary care a less attractive choice for medical school graduates. In 2015, almost 19,000 doctors graduated from American medical schools and only 7 percent of graduates chose a career in primary care.[15] The average age of a primary care physician in the United States is 47 years old, and one quarter of all primary care physicians are nearing retirement.[16] Fifty years ago roughly half of the physicians in America practiced primary care; today, fewer than one third of them do.[17]

The medical home model is intended to help coordinate care with the primary care provider the center of the patient's healthcare.[18][19]

US Strategies to Address the Primary Care Shortage

The Patient Protection Affordable Care Act contains a number of provisions to increase primary care capacity. These provisions are directed towards medical school graduates and include payment reform, student loan forgiveness programs and increased primary care residency positions [20] The PPACA also provides funding and mandates to increase the role of physician extenders like nurse practitioners and physician assistants to enhance the primary care workforce.[21] The PPCA is projected to increase patient demand for primary care services. Through the adoption of new patient care delivery models that include physicians working in tandem with nurse practitioners and physician assistants, demand for future primary care services could be met.[22] Consumer surveys have found the American public to be open to a greater role for physician extenders in the primary care setting.[23] Policies and laws, primarily at the state level, would need to redefine and reallocate the roles and responsibilities for non-physician licensed providers to optimize these new models of care.[24]

See also

References
  1. "WHO/Europe – Main terminology". who.int.
  2. World Health Organization. Definition of Terms. Archived 2011-03-03 at the Wayback Machine Accessed 24 June 2011.
  3. World Health Organization. International Classification of Primary Care, Second edition (ICPC-2). Geneva. Accessed 24 June 2011.
  4. World Health Organization. Ageing and life course: Our ageing world. Geneva. Accessed 24 June 2011.
  5. Simmons J. Primary Care Needs New Innovations to Meet Growing Demands. Archived 2011-07-11 at the Wayback Machine HealthLeaders Media, May 27, 2009.
  6. Burch, Patrick (19 December 2018). "Funding in primary care". InnovAiT: Education and Inspiration for General Practice. 12 (2): 100–104. doi:10.1177/1755738018805186.
  7. Royal Commission on the NHS Chapter 7. HMSO. July 1979. ISBN 0101761503. Retrieved 19 May 2015.
  8. Greenfield, Geva; Foley, Kimberley; Majeed, Azeem (23 September 2016). "Rethinking primary care's gatekeeper role" (PDF). BMJ. 354: i4803. doi:10.1136/bmj.i4803. hdl:10044/1/40789. PMID 27662893.
  9. Klepper, Brian; Al, Et (2012-10-02). "Strengthening Primary Care With A New Professional Congress". The Health Care Blog. Retrieved 2019-06-15.
  10. "Health Insurance Coverage and the Affordable Care Act, 2010–2016". ASPE. U.S. Department of Health & Human Services. Retrieved 30 May 2017.
  11. "AAMC Physician Workforce Policy Recommendations" (PDF). Association of American Medical Colleges.
  12. Finney, Karen (25 October 2010). "Wage gap between specialists, primary-care physicians". UC Newsroom.
  13. Finney, Karen (18 September 2012). "New Study Identifies Large Gaps in Lifetime Earnings of Specialist and Primary-care Physicians".
  14. "Total Number of Medical School Graduates". statehealthfacts.org. The Henry J. Kaiser Family Foundation.
  15. American Academy of Family Physicians (AAFP). Advancing Primary Care". Council on Graduate Medical Education: Twentieth Report. December 2010.
  16. "The Number of Practicing Primary Care Physicians in the United States". U.S. Department of Health and Human Services. Retrieved 30 May 2017.
  17. HealthITSecurity (2016-06-03). "Breaking Down the Basics of the Patient-Centered Medical Home". HealthITAnalytics. Retrieved 2019-05-20.
  18. April 24, Scott Wooldridge |; AM, 2019 at 10:32. "Primary care 'medical home' model catching on, slowly". BenefitsPRO. Retrieved 2019-05-20.
  19. Sommers, B.D. (2012). "New physicians, the affordable care act, and the changing practice of medicine". JAMA. 307 (16): 1697–98. doi:10.1001/jama.2012.523. PMID 22535852.
  20. Furrow, B.R. (2013). Health law; Cases, materials, and problems. Upper Saddle River: West Publishing Company.
  21. Bodenheimer, T.S. (2013). "Proposed Solutions to the physician shortage without training more physicians". Health Affairs (Project Hope). 32 (11): 1881–1886. doi:10.1377/hlthaff.2013.0234. PMID 24191075.
  22. Dill, M.J. (2012). "Survey shows consumers open to a greater role for physician assistants and nurse practitioners". Health Affairs (Project Hope). 32 (6): 1135–1142. doi:10.1377/hlthaff.2012.1150. PMID 23733989.
  23. Bodenheimer, T.S. (2013). "Primary Care : Proposed Solutions to the physician shortage without training more physicians". Health Affairs (Project Hope). 32 (11): 1881–1886. doi:10.1377/hlthaff.2013.0234. PMID 24191075.
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